Statin use in low-income and middle-income countries
Authors: Florian Neuhann, Tapiwa Kumwenda, Melani Ratih Mahanani, Tom Heller, Hans-Michael Steffen
Journal: The Lancet Global Health (2022)

In their Article, Maja Marcus and colleagues (March, 2022)1Marcus ME Manne-Goehler J Theilmann M et al.Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data.Lancet Glob Health. 2022; 10: e369-e379Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar report on primary prevention of cardiovascular disease for individuals aged 40–69 years with respect to WHO-recommended indications for drug treatment with statins. They found that approximately 10% of the individuals from health surveys of different low-income and middle-income countries were eligible for statins, but only 10% (1% of all individuals surveyed) of those eligible actually received a statin.1Marcus ME Manne-Goehler J Theilmann M et al.Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data.Lancet Glob Health. 2022; 10: e369-e379Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar In view of this low coverage, they call for the implementation of statin therapy into primary health care. Although there is a lot of merit in discovering the prevention gap on the basis of large datasets, these analyses have to be accompanied by localised contextual data before translation into health policy. In Malawi, hypercholesterinaemia was diagnosed in 0 ·1–0·3% of individuals aged 45–69 years in a population-based survey in 2017 and a total of 9·1% were considered to have or be at high risk of cardiovascular disease.2Ministry of HealthMalawi national STEPwise survey for non-communicable diseases risk factors 2017 report.https://cdn.who.int/media/docs/default-source/ncds/ncd-surveillance/data-reporting/malawi/2017-steps-survey-report-malawi.pdf?sfvrsn=1a2cc491_1&download=trueDate accessed: February 28, 2022Google Scholar Within our prospective LighTen cohort study of adults living with HIV taking tenofovir-based antiretroviral therapy (NCT02381275), we identified 462 participants who were aged 40 years or older (32·2% of the total study population). Among these 462 participants, 11 (2%)—including nine self-reported individuals with diabetes—would have qualified for statin treatment following WHO recommendations.3WHOHEARTS technical package for cardiovascular disease management in primary health care: risk-based CVD management. World Health Organization, Geneva2020Google Scholar However, hypertension was uncontrolled in 27 (73%) of 37 people living with HIV on antihypertensive treatment, or was newly detected in 173 (13·4%) of 1288 enrolled patients with blood pressure measurements on two or more occasions. Similar rates for the prevalence of diabetes (2·6%) and hypertension (14·7%) were found in the general Malawian population.4Price AJ Crampin AC Amberbir A et al.Prevalence of obesity, hypertension, and diabetes, and cascade of care in sub-Saharan Africa: a cross-sectional, population-based study in rural and urban Malawi.Lancet Diabetes Endocrinol. 2018; 6: 208-222Summary Full Text Full Text PDF PubMed Scopus (135) Google Scholar We published the results of a survey in 2021 comprising 100 people with obesity or overweight who were living with HIV on antiretroviral therapy to measure the prevalence of diabetes, hypertension, and lipid-lowering drug treatment requirements5Kumwenda T Buleya S Matanje B et al.Cardiovascular risk assessment for primary prevention in Malawian HIV patients on ART: are measurements of glycated hemoglobin and lipids worth the effort?.AIDS. 2021; 35: 997-999Crossref PubMed Scopus (1) Google Scholar using the WHO laboratory-based risk prediction charts3WHOHEARTS technical package for cardiovascular disease management in primary health care: risk-based CVD management. World Health Organization, Geneva2020Google Scholar to estimate cardiovascular risk. Hypertension was uncontrolled in 28 (82%) of 34 patients who were treated for hypertension and newly detected in seven (11%) of the remaining 66 individuals included in the survey. Five (5%) patients with newly detected diabetes would have qualified for statin treatment, but none of the people without diabetes living with HIV would have qualified. Although the proportion of people living with HIV with treatable cardiovascular risk factors was high, lipid measurements turned out to be of questionable value for cardiovascular risk stratification in primary prevention. With per-capita spending for health currently estimated to be US$39, urgently needed funds for the reduction of cardiovascular disease burden need to be targeted to the most meaningful areas in primary health care. It seems that the largest impact on cardiovascular risk reduction can be expected from adequate treatment of hypertension and screening for diabetes at least in very low-income countries like Malawi. We declare no competing interests. Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level dataIn a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future. Full-Text PDF Open AccessStatin use in low-income and middle-income countries – Authors' replyAuthors' reply We thank Florian Neuhann and colleagues for their interest in our study on statin use in low-income and middle-income countries. We agree with many of their points. Large datasets can aid in understanding treatment gaps. Local data should inform the intervention priorities of policy makers—not just for statins but for all health system investments. Scaling up treatment of hypertension and diagnosis of diabetes are also global cardiovascular health priorities. We wish to make a few additional comments. Full-Text PDF Open Access